Implications of remote monitoring Technology in Optimizing Traditional Self-Monitoring of blood glucose in adults with T2DM in primary care.

BACKGROUND: Self-monitoring of blood glucose (SMBG) has been shown to reduce hemoglobin A1C (HbA1C). Accordingly, guidelines recommend SMBG up to 4-10 times daily for adults with type 2 diabetes (T2DM) on insulin. For persons not on insulin, recommendations are equivocal. Newer technology-enabled blood glucose monitoring (BGM) devices can facilitate remote monitoring of glycemic data. New evidence generated by remote BGM may help to guide best practices for frequency and timing of finger-stick blood glucose (FSBG) monitoring in uncontrolled T2DM patients managed in primary care settings. This study aims to evaluate the impact of SMBG utility and frequency on glycemic outcomes using a novel BGM system which auto-transfers near real-time FSBG data to a cloud-based dashboard using cellular networks. METHODS: Secondary analysis of the intervention arm of a comparative non-randomized trial with propensity-matched chart controls. Adults with T2DM and HbA1C > 9% receiving care in five primary care practices in a healthcare system participated in a 3-month diabetes boot camp (DBC) using telemedicine and a novel BGM to support comprehensive diabetes care management. The primary independent variable was frequency of FSBG. Secondary outcomes included frequency of FSBG by insulin status, distribution of FSBG checks by time of day, and hypoglycemia rates. RESULTS: 48,111 FSBGs were transmitted by 359 DBC completers. Participants performed 1.5 FSBG checks/day; with 1.6 checks/day for those on basal/bolus insulin. Higher FSBG frequency was associated with greater improvement in HbA1C independent of insulin treatment status (p = 0.0003). FSBG frequency was higher in patients treated with insulin (p = 0.003). FSBG checks were most common pre-breakfast and post-dinner. Hypoglycemia was rare (1.2% < 70 mg/dL). CONCLUSIONS: Adults with uncontrolled T2DM achieved significant HbA1C improvement performing just 1.5 FSBGs daily during a technology-enabled diabetes care intervention. Among the 40% taking insulin, this improvement was achieved with a lower FSBG frequency than guidelines recommend. For those not on insulin, despite a lower frequency of FSBG, they achieved a greater reduction in A1C compared to patients on insulin. Low frequency FSBG monitoring pre-breakfast and post-dinner can potentially support optimization of glycemic control regardless of insulin status in the primary care setting. TRIAL REGISTRATION: Trial registration number: NCT02925312 (10/19/2016).

Inpatient Diabetes Education in the Real World: an Overview of Guidelines and Delivery Models.

PURPOSE OF REVIEW: Diabetes self-management education and support improves diabetes-related outcomes, yet less than 50% of persons with diabetes in the USA receive this service. Hospital admissions present a critical opportunity for providing diabetes education. This article presents an overview of the current state of inpatient diabetes education. It incorporates a summary of existing guidance relative to content followed by an overarching discussion of existing inpatient diabetes education models and their reported outcomes, when available. RECENT FINDINGS: As diabetes rates continue to soar and adults with diabetes continue to have high hospitalization and readmission rates, hospitals face challenges in assessing and meeting diabetes patients' educational needs. The consensus recommendation for inpatient diabetes teaching is to provide survival skills education to enable safe self-management following discharge until more comprehensive outpatient education can be provided. Established and emerging models for delivery of diabetes survival skills education in the hospital may be broadly grouped as diabetes-specialty care models, diabetes non-specialty care models, and technology-supported diabetes education. These models are often shaped by the availability of diabetes specialists, including endocrinologists and diabetes educators-or lack thereof, and staffing resources for provision of services. Recent studies suggest that all three approaches can be deployed successfully if well planned. This article presents an overview of the current state of inpatient diabetes education. It incorporates a summary of existing guidance relative to content followed by an overarching discussion of existing inpatient diabetes education models and their reported outcomes, when available. The authors seek to make the reader aware of the heterogeneous approaches that are being implemented nationwide for inpatient diabetes education delivery. Meeting inpatient diabetes educational needs will require a sustained effort, diverse strategies based on resources available, and additional research to explore the impact of these strategies on outcomes.

Acute Kidney Injury and In-Hospital Mortality after Coronary Artery Bypass Graft versus Percutaneous Coronary Intervention: A Nationwide Study.

BACKGROUND: Post-procedural acute kidney injury (AKI) is associated with significantly increased short- and long-term mortalities, and renal loss. Few studies have compared the incidence of post-procedural AKI and in-hospital mortality between 2 major modalities of revascularization - coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) - and results have been inconsistent. METHODS: We generated a propensity score-matched cohort that includes a total of 286,670 hospitalizations with multi-vessel coronary disease undergoing CABG or PCI (2004-2012) from the National Inpatient Sample database. We compared incidence of AKI, AKI requiring renal replacement therapy (RRT), in-hospital mortality, hospital stay, and charges between CABG and PCI groups. RESULTS: The incidence of AKI after CABG was higher than PCI (8.9 vs. 4.5%, OR 2.05, 95% CI 1.99-2.12, p < 0.001). The incidence of AKI requiring RRT was also higher after CABG (1.1 vs. 0.5%, OR 2.14, 95% CI 1.96-2.34, p < 0.001). Likewise, in-hospital mortality was higher after CABG than PCI (2.0 vs. 1.4%, OR 1.44, 95% CI 1.35-1.52, p < 0.001). Among patients with pre-existing chronic kidney disease (stages I-IV), those undergoing CABG was associated with 2.0-2.3-fold higher odds of developing AKI than those undergoing PCI. The patients treated with CABG had a significantly longer hospital stay and higher hospital charges. CONCLUSIONS: Patients undergoing CABG are associated with (1) increased risk of developing post-procedural AKI, (2) higher likelihood of receiving RRT, and (3) worse short-term survival. Long-term renal outcome remains to be studied.

Pilot feasibility and efficacy of a strategy to sustain A1C improvement among diverse adults with type 2 diabetes completing a diabetes care management program.

INTRODUCTION: Evidence-based strategies are needed to sustain improvements in outcomes following diabetes care management (DCM) programs. We examined the impact of Boot Camp-Plus (BC-Plus), an innovative sustaining strategy, on A1C among adults with type 2 diabetes completing a 3-month Diabetes Boot Camp (DBC). This health system sponsored program consisted of diabetes self-management education and support, medical nutrition therapy and antihyperglycemic medications management. RESEARCH DESIGN AND METHODS: From March 2019 to July 2021, adult DBC completers with Medicare or a health system Medicaid or employee commercial plan were enrolled in BC-Plus for 9 months. DBC completers not meeting insurance eligibility or who declined to participate in BC-Plus acted as controls. During the first 3 months, BC-Plus participants received ongoing daily remote blood glucose (BG) monitoring; and during all 9 months, they received monthly check-in calls with BG review by a medical assistant who addressed needs for supplies/drugs, whether participants were checking BGs, and self-care encouragement. Escalation to a nurse practitioner occurred if the monthly BG trend was >200 mg/dL and/or several BG <80 mg/dL and/or new A1C >9.0% were identified. A1C was followed for an additional 9 months post-BC-Plus. A longitudinal mixed effects analysis was used to assess change in A1C from month 0 to month 21 of follow-up between BC-Plus participants versus controls. RESULTS: A total of 838 DCM completers were identified, among whom 281 joined the BC-Plus intervention and 557 acted as controls. Mean age was 55.9 years; 58.2% were women; 66.2% were black; and 30.6% insured by Medicare. BC-Plus participants experienced significantly lower A1C compared with controls and remained below 8.0% to month 18. CONCLUSIONS: Among completers of a 3-month DCM program, a low intensity 9-month sustaining strategy maintained A1C under 8.0% (HEDIS (Healthcare Effectiveness Data and Information Set) threshold for diabetes control) compared with controls for 15 months after completion of the initial DCM intervention.

Consensus on pharmacological treatment of obesity in Latin America.

A panel of 10 experts in obesity from various Latin American countries held a Zoom meeting intending to reach a consensus on the use of anti-obesity medicines and make updated recommendations suitable for the Latin American population based on the available evidence. A questionnaire with 16 questions was developed using the Patient, Intervention, Comparison, Outcome (Result) methodology, which was iterated according to the modified Delphi methodology, and a consensus was reached with 80% or higher agreement. Failure to reach a consensus led to a second round of analysis with a rephrased question and the same rules for agreement. The recommendations were drafted based on the guidelines of the American College of Cardiology Foundation/American Heart Association Task Force on Practice. This panel of experts recommends drug therapy in patients with a body mass index of ≥30 or ≥27 kg/m2 plus at least one comorbidity, when lifestyle changes are not enough to achieve the weight loss objective; alternatively, lifestyle changes could be maintained while considering individual parameters. Algorithms for the use of long-term medications are suggested based on drugs that increase or decrease body weight, results, contraindications, and medications that are not recommended. The authors concluded that anti-obesity treatments should be individualized and multidisciplinary.

Feasibility and Preliminary Behavioral and Clinical Efficacy of a Diabetes Education Chatbot Pilot Among Adults With Type 2 Diabetes.

BACKGROUND: Diabetes self-management education and support (DSMES) improves diabetes outcomes yet remains consistently underutilized. Chatbot technology offers the potential to increase access to and engagement in DSMES. Evidence supporting the case for chatbot uptake and efficacy in people with diabetes (PWD) is needed. METHOD: A diabetes education and support chatbot was deployed in a regional health care system. Adults with type 2 diabetes with an A1C of 8.0% to 8.9% and/or having recently completed a 12-week diabetes care management program were enrolled in a pilot program. Weekly chats included three elements: knowledge assessment, limited self-reporting of blood glucose data and medication taking behaviors, and education content (short videos and printable materials). A clinician facing dashboard identified need for escalation via flags based on participant responses. Data were collected to assess satisfaction, engagement, and preliminary glycemic outcomes. RESULTS: Over 16 months, 150 PWD (majority above 50 years of age, female, and African American) were enrolled. The unenrollment rate was 5%. Most escalation flags (N = 128) were for hypoglycemia (41%), hyperglycemia (32%), and medication issues (11%). Overall satisfaction was high for chat content, length, and frequency, and 87% reported increased self-care confidence. Enrollees completing more than one chat had a mean drop in A1C of -1.04%, whereas those completing one chat or less had a mean increase in A1C of +0.09% (P = .008). CONCLUSION: This diabetes education chatbot pilot demonstrated PWD acceptability, satisfaction, and engagement plus preliminary evidence of self-care confidence and A1C improvement. Further efforts are needed to validate these promising early findings.

Future technology-enabled care for diabetes and hyperglycemia in the hospital setting.

Patients with diabetes are increasingly common in hospital settings where optimal glycemic control remains challenging. Inpatient technology-enabled support systems are being designed, adapted and evaluated to meet this challenge. Insulin pump use, increasingly common in outpatients, has been shown to be safe among select inpatients. Dedicated pump protocols and provider training are needed to optimize pump use in the hospital. Continuous glucose monitoring (CGM) has been shown to be comparable to usual care for blood glucose surveillance in intensive care unit (ICU) settings but data on cost effectiveness is lacking. CGM use in non-ICU settings remains investigational and patient use of home CGM in inpatient settings is not recommended due to safety concerns. Compared to unstructured insulin prescription, a continuum of effective electronic medical record-based support for insulin prescription exists from passive order sets to clinical decision support to fully automated electronic Glycemic Management Systems. Relative efficacy and cost among these systems remains unanswered. An array of novel platforms are being evaluated to engage patients in technology-enabled diabetes education in the hospital. These hold tremendous promise in affording universal access to hospitalized patients with diabetes to effective self-management education and its attendant short/long term clinical benefits.

Redesigning ambulatory care management for uncontrolled type 2 diabetes: a prospective cohort study of the impact of a Boot Camp model on outcomes.

Objective: Type 2 diabetes care management (DCM) is challenging. Few studies report meaningful improvements in clinical care settings, warranting DCM redesign. We developed a Boot Camp to provide timely, patient-centered, technology-enabled DCM. Impact on hemoglobin A1c (HbA1c), emergency department (ED) visits and hospitalizations among adults with uncontrolled type 2 diabetes were examined. Research design and methods: The intervention was designed using the Practical Robust Implementation and Sustainability Model to embed elements of the chronic care model. Adults with HbA1c>9% (75 mmol/mol) enrolled between November 2014 and November 2017 received diabetes education and medication management by diabetes educators and nurse practitioners via initial clinic and subsequent weekly virtual visits, facilitated by near-real-time blood glucose transmission for 90 days. HbA1c and risk for ED visits and hospitalizations at 90 days, and potential savings from reducing avoidable medical utilizations were examined. Boot Camp completers were compared with concurrent, propensity-matched chart controls receiving usual DCM in primary care practices. Results: A cohort of 366 Boot Camp participants plus 366 controls was analyzed. Participants were 79% African-American, 63% female and 59% Medicare-insured or Medicaid-insured and mean age 56 years. Baseline mean HbA1c for cases and controls was 11.2% (99 mmol/mol) and 11.3% (100 mmol/mol), respectively. At 90 days, HbA1c was 8.1% (65 mmol/mol) and 9.9% (85 mmol/mol), p<0.001, respectively. Risk for 90-day all-cause hospitalizations decreased 77% for participants and increased 58% for controls, p=0.036. Mean potential for monetization of US$3086 annually per participant for averted hospitalizations were calculated. Conclusions: Redesigning diabetes care management using a pragmatic technology-enabled approach supported translation of evidence-based best practices across a mixed-payer regional healthcare system. Diabetes educators successfully participated in medication initiation and titration. Improvement in glycemic control, reduction in hospitalizations and potential for monetization was demonstrated in a high-risk cohort of adults with uncontrolled type 2 diabetes. Trial registration number: NCT02925312.

Epidemiology of needlesticks and other sharps injuries and injection safety practices in the Dominican Republic.

BACKGROUND: Contaminated sharps, such as needles, lancets, scalpels, broken glass, specimen tubes, and other instruments, can transmit bloodborne pathogens such as HIV, hepatitis B (HBV), and hepatitis C viruses (HCV). METHODS: Observation of facilities and injections and questionnaire-guided interviews were conducted in 2005 among health care workers (HCWs) in 2 public hospitals in Santo Domingo and 136 public immunization clinics (IC) in the Dominican Republic. Injection practices and sharps injuries (SIs) in health care facilities in the Dominican Republic were assessed in cross-sectional surveys to identify areas in which preventive efforts might be directed to make injection practices safer. RESULTS: Of the 304 hospital HCWs and 136 ICs HCWs interviewed, 98 (22.3%) reported > or =1 SIs during the previous 12 months. ICs had a lower incidence (13 per 100 per person-years [p-y]) of SIs than hospitals (65 per 100 p-y) (P < .0001). Unsafe needle recapping was observed in 98% of all injections observed at hospitals but in only 12% of injections at ICs (P < .0001). Sharps were observed improperly disposed in regular waste containers in 24 (92%) of 26 areas at which injections are prepared at the hospitals but in only 11 (8%) of 136 ICs (P < .0001). Training in injection safety was received by 4% of HCWs in hospitals but by 77% in ICs (P < .001). Of 425 HCWs, 247 (58%) were fully immunized against hepatitis B. There was a higher risk of SIs among staff dentists (adjusted relative risks [aRR], 5.9; 95% confidence interval [CI]: 2.8-12.6), resident physicians (aRR, 3.5; 95% CI: 1.8-6.9), and those who gave > or =11 therapeutic injections per day (aRR, 1.6; 95% CI: 1.1-2.4). CONCLUSION: Injection practices at ICs were safer than those found at public hospitals. Preventive strategies to lower SIs in public hospitals should include regular training of hospital staff to minimize needle recapping and improper disposal, among other interventions to reduce the dangers of needles.

[Mandibular advancement devices for the treatment of adult sleep respiratory disorders]. / Dispositivos de avance mandibular para el tratamiento de los trastornos respiratorios del sueño del adulto.

INTRODUCTION: Mandibular advancement devices are being shown to be increasingly useful in the treatment of adult respiratory sleep disorders. A prospective study was started in April 2008 to apply 40 devices free of charge, with the aim of assessing their usefulness in our patients. MATERIAL AND METHODS: The device was applied to 40 patients with an apnoea-hypopnoea index of less than 40. All the cases snored, with 52.5% observed apnoeas and 47.5% diurnal sleepiness. RESULTS: With a minimum follow-up of six months, the cases that snored decreased to 59%, most with a significantly lower intensity; 8.8% of cases had observed apnoeas and 14.7% mentioned diurnal sleepiness. There was an overall clinical improvement in 31 (91.2%) patients. The mean apnoea-hypopnoea index fell to 8.4+/-9.6 and polysomnographic improvement could be seen in 25 (75%) cases. An overall positive result, showing subjective as well as objective improvement, was obtained in 23 (69.7%) patients. Two patients stopped using the device in the first few days and another patient after six months. Complications were relatively common, but always slight. Compliance levels were satisfactory: a mean of 6.5+/-1.1 nights per week and 7.4+/-1.09 days per week. CONCLUSION: Mandibular advancement devices are an effective therapeutic option for the treatment of respiratory sleep disorders. Compliance levels can be satisfactory if working with an expert odontology team.

A novel housestaff educational model for quaternary-care patients at an academic health center.

PURPOSE: Work hour restrictions, external pressure to reduce hospitalization costs, and rising inpatient acuity have prompted a variety of changes in the ward-based educational models traditionally employed in residency training. The impact of these changes remains largely unstudied. METHOD: The authors collected data retrospectively on hospital patients with advanced liver disease before (July 1, 2003, to May 31, 2004) and after (July 1, 2004, to May 31, 2005) implementation of a novel specialized housestaff service (SHS) model for those patients, supervised by a multidisciplinary hepatology team led by an attending hepatologist. The authors also assessed the satisfaction of the 118 internal medicine residents who had rotated through both the SHS model and a traditional housestaff service (THS) in cardiology. RESULTS: In univariate analysis, there was a trend toward a reduction in mean length of stay (LOS) after implementation of the liver service that did not meet statistical significance (P = .1). After adjustment for patient acuity and Model-for-End-Stage-Liver-Disease score, implementation of the liver service was associated with a statistically significant reduction in LOS (P = .05). In contrast, during the study period, there was an increase in LOS on a comparable, nonspecialized medicine housestaff ward even after adjustment for patient acuity (P < .01). With respect to housestaff satisfaction, 90% of housestaff reported being satisfied overall with their experience caring for patients under the SHS model, with a mean score of 4.1 on a 5-point scale. CONCLUSION: The implementation of the SHS model of patient care is associated with a decreased LOS and increased trainee satisfaction when compared with the THS model of patient care.

Equilibrio sodio-potasio en la regulación de la hipertensión arterial / Sodium-potassium balance in the regulation of high blood pressure

La hipertensión arterial esencial es considerada como la principal causa de muerte por la OMS. La cuarta parte de la población mayor de 15 años es hipertensa, lo que representa aproximadamente un billón de personas, que tendrán un importante aumento en el año 2025 cercano al 60 por ciento. Su prevalencia aumenta en proporción lineal con el aumento de edad. Desafortunadamente, los niveles de detección, tratamiento y control efectivo de la hipertensión arterial, son deficientes a nivel de Chile y mundial, por lo que es aún un problema de salud pública no resuelto y que por tanto necesita urgente atención. La reciente Encuesta Nacional Ministerial de Salud 2009-2010 de Chile reveló una prevalencia de hipertensión arterial nacional de un 26,9 por ciento, con un 65 por ciento de conocimiento de su existencia, 37,6 por ciento en tratamiento y sólo un 16,49 por ciento de control satisfactorio. Además, dicha encuesta revela marcadores de estilos de vida poco saludables, que permiten comprender la epidemia nacional de hipertensión arterial, a través de la existencia de múltiples factores de riesgo para ella. En esta revisión nos centramos especialmente en la importancia de la relación sodio-potasio en la regulación de la presión arterial. Llama la atención que todos los estudios destacan la importancia que tiene el sodio en la génesis de la hipertensión arterial por sus efectos presores, particularmente en sujetos sensibles, y poco o nada se manifieste de las variadas acciones benéficas que posee el potasio en la regulación de la presión arterial.

The World Health Organization considers essential hypertension as a primary cause of death. Twenty-five percent of the population over 15 has high blood pressure (HBP), equivalent to a billion people. It has been predicted that this group will increase by 60 percent, lineal with age increase in the overall population. Unfortunately, detection, treatment and effective control of HBP, are deficient both in Chile and in the rest of the world, making it an unresolved health problem demanding urgent attention. The recently conducted Chilean National Health Survey (2009-2010) revealed a 26.9 percent prevalence of this condition in the population, sixty-five percent of individuals are aware of their condition, 37.6 percent are in treatment and only 16,49 percent are effectively controlled. Furthermore, the survey reveals unhealthy life-style markers, which explains the epidemic that besets the country as there are multiple risk factors at stake. This review focuses mainly on the importance of the sodium-potassium relationship in the regulation of high blood pressure. It must be pointed out that all of the studies underscore the importance of sodium in the genesis of hypertension because of its effects of blood pressure, especially in sensitive individuals, while little attention has been given to the manifold beneficial actions of potassium in the regulation of blood pressure.